John Miner, MD Williams College Williamstown, Massachusetts

1. Multiple Roles and Multiple Conversations:Challenges for College Mental Health ACHA FR102Friday, May 29, 2009San Francisco John Miner, MD Williams College Williamstown, Massachusetts

2. A.K.A. The Ivory Towers of Babel

3. Premise # 1 • Role for College Mental Health Professionals has expanded as the mental health awareness of college students has growth in our culture. • In loco parentis • ‘In parentis absentia’ • ‘In parentis de novo’ • Multiple Roles

4. Premise #2 • Student Affairs / Services staff are increasingly aware and involved in the education and development of students NCHA data Place of ‘counseling’ in education Multiple Conversations

5. Premise #3 • Many of the difficulties that colleges experience in working with students with challenging developmental and mental health needs arise from conflicts and confusion about staff’s roles and values.

6. Multiple Roles (Voices) of a College Mental Health Professional • Robert May, PhD (1986) Boundaries and Voices in College Psychotherapy - psychotherapy voice - counseling voice - medical voice - administrative voice

7. Psychotherapy voice (Explore) • Voice of exploration and meaning • Language is “why” • Rule of restraint…foreswear influence on the OTHER’s behavior and activities • “expressive” therapy • Importance of ‘frame’

8. Counseling Voice (Support) • Voice of advising, directing a CLIENT • Language is “why don’t you…” • “suppressive or supportive” therapy • Most common ‘voice’ in student affairs • Less focused on ‘frame’

9. Medical Voice (Heal) • Voice of relieving pain and suffering in PATIENTS • Language is “let’s look”, “diagnose and fix” • Authoritarian • Health Center ‘frame’

10. Administrative Voice (Provide) • Voice of policies and boundaries • Acknowledges resources required for the work of staff and roles • Language is often ‘yes’ or ‘no’ • Institutional support of ‘frames’

11. Multiple Roles – Vertical Axis

12. Clinical examples • Walk in or New Intake Assessment Diagnosis/No Diagnosis Recommendation Plan • Student in treatment change in MSE self destructive or self injurious behaviors suicidal thinking

13. Other Aspects ofRole Knowledge Skills Values Culture

14. Multiple Conversations • Early higher education – talk to anyone you could find faculty – especially Psychology Departments deans health personnel 1914 American Social Hygiene Association 1918 American Student Health Association 1920 American College Health Association

15. Frankwood E. Williams, MD1920 addressAmerican Student Health Association Needs and goals for Mental Health Programs in College • The conservation of the student body, so that intellectually capable students may not be forced to withdraw but may be retained. • The forestalling of failure in the form of nervous and mental diseases, immediate or remote. • The minimizing of partial failure in later mediocrity, inadequacy, inefficiency and unhappiness. • The making possible of a large individual usefulness by giving to each a fuller use of the intellectual capacity he possesses, through widening the sphere of social control

16. Evolution of Student Affairs • 1918 Deans and Advisors of Men (DAM) • 1928 National Association of Deans and Advisors of Men (NADAM) • 1937 American Council on Education Student Personnel Point of View • World War II • 1951 National Association of Student Personnel Administrators (NASPA) • In loco parentis

17. Student Affairs evolution – continued • 1960’s – rise of dissent and students’ rights • 1974 FERPA • NASPA becomes Student Affairs Administrators in Higher Education • 1987 Chickering and Gamson Principles of Good Practice for Student Affairs • American College Personnel Association (ACPA) 1994 The Student Learning Imperative

18. 1987 Principles of Good Practice for Student Affairs • Student-faculty contact • Cooperation among students • Active learning • Prompt feedback • Time on task • High expectations • Respect for diverse talents and ways of learning

19. 1994 The Student Learning ImperativePrinciples of Good Practice • Engages students in active learning • Helps students develop coherent values and ethical standards • Sets and communicates high expectations for student learning • Uses systematic inquiry to improve student and institutional performance • Uses resources effectively to achieve institutional missions and goals • Forges educational partnerships that advance student learning • Builds supportive and inclusive communities

20. Dana Farnsworth,MD1953 The psychiatrist’s main responsibility to the college is to awaken an awareness or a sensitivity to this great range of personal problems. It is not his purpose to develop amateur psychologists out of teachers. His job is to help them become better teachers. To be good teachers, they should be good counselors. Every contact with the student is in reality a counseling situation.

21. Evolution of College Mental Health Services • Evolution of Psychiatric and Health Services before and after WW II development of medications • Evolution of Counseling Services Dean’s Offices and Psychology Departments WWII – brief treatment models testing tools • Rise in field of Clinical Psychology - 1972 Stanford – 1st combined CAPS

22. Student Affairs – The Horizontal Axis

23. Student AffairsDean of Students • Office of the Dean • Safety – Security • Residential Life • Academic Advising • Health Services • Multicultural Center • Admissions • Buildings – Grounds – Dining Services

24. Health Services • Medical care • Nutritional Counseling • Health Education/Promotion • Substance Abuse Counseling • Psychiatric Services • Counseling Services

25. Health Service ‘Babel” • Self Injurious Behaviors • Psychosomatic Illnesses • Addictions • Dual Diagnosis • Eating Disorders • Depression Screening • Nurses as Triage

26. Health Service – Confidentiality(within Health Center) • Usually separate records • Confidentiality - medical - counseling • Development of Teams (i.e. ED team) • Need for Psychological Medicine Rounds

27. Case vignette - summary • Talented young writer • Long standing SIB • Several encouragements to engage in therapy • Disliked the ‘frame’ • Serious cutting episode – ER visit • STAR committee assessment – allowed to stay • Mandated treatment + chats with HC director • Thesis after graduation

28. Presented at NECHA WorkshopMultiple Roles • Structure of Workshop • Group Relations format • Inner circle and outer circle • Learning

29. RN (outside) “we don’t really care what happened to them when they were 5…we just need to know what medications they’re on… • Therapist (inside) “…it’s our professional ethics…”

30. Barriers to Communication • Professional Professional Ethics and Guidelines Policies and Procedures HIPPA, FERPA • Personal Knowledge, skills, values • Deeply Personal

31. Deeply personal

32. “Babel” occurs at the intersections of student affairs departments Dean’s Office – Health Services Residential Life – Health Services Safety/Security – Health Services Academic Advising – Health Services MCC – Health Services Admissions – Health Services

33. Office of the Dean – Health Services • Med – Psych Course reduction • Student at Risk Committees (STAR) • LOA – mandated or voluntary • Reinstatement process

34. Residential Life – Health Services • Training and supervision of Res Life staff • Problems in community living • Outreach

35. Safety – Security - Health Services • Emergency assessments • Wellness checks • Hospital transports • Substance Use / Abuse

36. Academic Advising – Health Services • Accomodations • ADHD • Tutors and other services

37. MCC – Health Services • Cultural competence training • Access to services • Outreach

38. Admissions – Health Services • “What were they thinking…?”

39. Role of Consultant

40. Consultation • Work of Gerald Caplan, MD • Interaction between 2 professionals • Consultant = specialist • Consultee = has a work problem* *of a mental health related nature

41. Consultation - features • No administrative responsibility (different than supervision) • Usually brief in each case, but regular contact • Work problems continue to arise • Task is improving work problem • Consultation is not personal – not therapy • If clinical danger exists, change to clinician

42. Types of Consultation • Client centered consultation -specific client -consultee’s problems with specific clients • Program/Group centered consultation - specific program development - consultee’s problems with program implementation

43. Developing Consultation Serviceswithin a College Community • Establish shared mission and goals • Build Relationships • Understand Multiple Roles • Develop shared language

44. Goals • Must be salient - meet the needs of the community - must help the mission of the institution - judgement on salience can be influenced by values • Must be feasible - resources - practicality

45. Building Relationships • Familiarity • Clarification of Contract • Confidentiality of consultant • Avoidance of ‘one downsmanship’ • Avoidance of psychotherapy

46. Recommendations • Establish work groups to discuss situations where mental health related issues create work problems • Clarify and understand what each group needs in order to do their work • Respectful negotiation of work related roles